Assignment task:
Dale Mayman is a 51-year old male on a medical unit with end-stage liver disease.
His wife is present and questioning liver transplant options.
Physician Note:
Dale Mayman has a known chronic liver disease secondary to alcoholic cirrhosis. He has abused alcohol for over 25 years (6-8 beers per day). Mr. Mayman has also a history of hypertension. He was found to have increased ammonia levels upon admission along with an elevated serum alcohol level. He has received valium to reduce his symptoms of abstinence.
Nurses Note:
Dale Mayman is a 51-year-old male with a known liver disease secondary to alcoholic cirrhosis admitted four days ago because of increased mental confusion. A diagnostic paracentesis was performed in the emergency department at admission and revealed spontaneous bacterial peritonitis (SBP). Antibiotic treatment has been initiated. Despite treatment Mr. Mayman has become hemodynamically unstable and was transferred to the intensive care unit for aggressive fluid replacement two days ago. Throughout the night he has had increased confusion and difficulty breathing requiring a face mask to maintain a saturation greater than 92%. This morning his breathing has become more labored and his wife is very upset about his decline over the last 24 hours. Mr. Mayman refuses to cooperate with his a.m. assessment and attempts several times to remove his oxygen.
Vital Signs:
BP: 110/64
HR: 74
RR: 18
SpO2: 93% on Venturi Mask
Temp: 100.1 F
Lab:
Serum ETOH: 0.14 (High)
Urine ETOH: 0.18 (High)
Bilirubin in urine: Trace (High)
Blood in urine: Trace (High)
Protein in urine: Trace (High)
Blood Culture 1 site: Large (High)
Blood Culture 2nd site: Large (High)
Urine tox screen Alcohol: Positive (High)
PT: 25 (High)
INR: 2.3 (High)
Ammonia: 320 (High)
Na: 130 (Low)
K: 3.1 (Low)
Mg: 1.0 (Low)
Cl: 92 (Low)
Calcium: 8.2 (Low)
Glucose: 13 (High)
Albumin: 2.9 (Low)
Alt: 321 (High)
AST: 528 (High)
Hgb: 12 (Low)
Hct: 38 (Low)
RBCs: 4.2 (Low)
WBCs: 11.9 (High)
Platelets: (133,000) (Low)
RDW: 14.6 (Low)
MCV: 78 (Low)
MCH: 25 (Low)
As a result of the SBAR, the following orders were given by the provider.
- Soft wrist restraints for line/equipment safety
- Midazolam 2 mg IV q 4 hours PRN for agitation
- Albumin 5% 10 grams IV infusion stat
- 0.9% Sodium Chloride 500 mL IV infusion bolus over 30 minutes
- Typed and cross for 2 units PRBCs
- Cardiac monitoring
Assessment:
Eyes: Jaundice
Orientation: Disoriented
Behavioral/Emotional: Restless, confused, agitated
Skin: Jaundiced, warm, Diaphoretic
Q1. What cues need follow up? What findings are of most concern?
Q2. Based on your identified cues, what possible disease processes exist? Group your findings that support these disease processes.
Q3. What are the priority concerns or highest risk/complication? Support with your evidence-why?
Q4. What potential interventions are needed for this patient? What are the contradictions if any?
Q5. What interventions need to be performed immediately? Think about 2-3 to do right away.
Q6. What findings would indicate an improvement or decline? How will you measure this?